Public rhetoric runs high, including fears of lower quality and increased medical negligence, as illustrated in the article I have linked above. It is interesting to think that this may also be about power. The expanded scope of practice bill for California's pharmacists has survived the same committee after all. So, what's the difference?

Actually, before yesterday, California had three interesting scope of practice bills pending:

SB491: Would allow nurse practitioners to establish independent practices and deliver the level of care their training permits without a physician's oversight, including being able to see Medi-Cal patients.

SB492: Would permit optometrists to examine, prevent, diagnose and treat conditions and disorders of the visual system and human eye. It would permit an optometrist to diagnose, treat
and manage additional conditions, and also to give vaccinations and perform primary care procedures requiring no more than topical or local anesthetic.

SB493: Would establish "advanced practice pharmacist" recognition status with specific training requirements, allowing such pharmacists to perform physical assessments, order and interpret medication-related tests, and refer patients to other providers.

One difference is the way SB493 has been amended to retain much of the power and authority of the work to be done by specialty pharmacists under the control of physicians. You can see an analysis of SB 493's different iterations here: >http://www.leginfo.ca.gov/pub/13-14/bill/sen/sb_0451-0500/sb_493_bill_20130528_amended_sen_v96.html>.

Sure, it is about compensation. But it is also about power and control.

September 21, 2012

Missouri is one of the most restrictive states in the U.S. for scope of practice for APRNs (advance practice nurses). Yet, parts of Missouri are greatly underserved by primary care practitioners (PCPs). Although we have what might be best described as a nationwide shortage of PCPs, the Center for Studying Health System Change has documented that that the shortage is particularly acute in southern and western states.

So, it could be worse here in Missouri. But, it could be better. And it might get much worse with the addition of a further 17 million Americans moving into insured status under the Affordable Care Act.

If we are stressed to provide PCP services in rural Missouri under the status quo (where an estimated 13 counties have only a CRNA -- Certified Registered Nurse Anesthetist-- to provide anesthesia services) what will happen if we expand Medicaid? Is this a reason not to expand Medicaid?

I sometimes hear this advanced as what I call the "we can't do it, so we shouldn't even try" argument, as if provider supply were immutable, immune from market forces. PCP supply is so tight -- the argument goes -- the whole system might collapse of its own weight if we further expand the pool of those seeking services.

This argument in favor of a rationing system based on grandfathering in the previously insured leaves me non-plussed. Yet, it is a argument with considerable purchase in some health care reform debate circles. It is, after all, the thinking behind widely discussed proposals to repeal the ACA but retain the provisions extending family health insurance coverage to children of insured families until the age of 26.

The rationale -- accident of birth, consanguinity or affinitity as a preference for insured status -- seems to me to be close to arbitrary. The rationale for favoring employer based health insurance is in rewarding valued employees, not their 25 year old married, independent tax status, employed elsewhere offspring.

Similarly, the argument that Missouri not confront head on its primary care provider shortage as a form of health care rationing also seems arbitrary.

Scope of practice regimens -- including Missouri's restrictive collaborative practice requirements restricting phsycians-CRNA collaboration to a 3:1 ration-- are not accidents of nature or, even, next best systems thrown together in a world of limited resources. They are programmatically designed to restrict the provision of PCP services by APRNs in Missouri. This they do very well.

Whether the solution to the PCP shortage is to loosen scope of practice constraints on APRNs or to increase PCP phsyician supply, we might best start by owning the problem and owning our own role in creating the problem.